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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUIV-KEFUNDAHLE PERMIT <br />JOB ADDRESS 9559LELAND WAY <br />CROSS STREET ASHLEY <br />OWNER NAME GENT DAVIS <br />OWNER ADDRESS 9622 LELAND WAY <br />GALL (LUtJ) yb3-/bU1 FOR INSPECTIONS t_AIJIKhb 9 YEAR FROM DATE ISSUED <br />CITY/ZIP STOCKTON 95212 <br />APN 08510216 PARCEL SIZE 1 ACRE LAND USE APPLICATION # <br />PHONE 209-612-7912 <br />CITY/STATE/ZIP STOCKTON. CA 95212 <br />CONTRACTOR GOLDEN STATE IRRIGATION & PUMP SERVICE <br />CONTRACTOR ADDRESS 4500 E FREMONT <br />SUBCONTRACTOR N/A <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 CK C-61 ❑ D-09 ❑ Other <br />PHONE 209-943-7774 <br />CITY/STATE/ZIP STOCKTON. CALIF 95215 <br />CITY/STATE/ZIP <br />NUMBER 979833 <br />PHONE <br />EXPIRATION DATE 12/31/22 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) CI Arsanic (4393) <br />INTENDED USE CX Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number 01 <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other CC,, <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of qo ngs 4 <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair N <br />❑ New Pum IX Pum Replacement ❑ Pum Repair 11 Raise Well Casing3q `� <br />WELL CONSTRUCTION /V Q(� <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other hFq� HRONMN Dov <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in tg1' r <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />)EDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length It Thick <br />❑ Christy Box ❑ Stove Pipe <br />PUMP R Submersible❑ Turbine ❑ Other HP 1/2 Pump Set 105 ft Standing Water Level 84 ft <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following items: GPS <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing wells, structures, <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic, <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposed well. <br />MINI\II ,bt 24 1101 R ADN AN( 1, 1,01 WERFOI'IRLD FOR INSPLC I IONS - I'LL'.,kSI': ('% 1A, 1200) 0:.3--69? <br />*� DEPARTMENT USE ONLY <br />Application Accepted By �/� f��l Date S oT <br />Grout Inspection By Date <br />Pump Inspection By Date <br />a <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area 4 9-rf Employee ID# Fr,-,)Ik <br />❑ SPECIAL Well Permit <br />❑ WAIVER received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info Bv Cash Remitted Service Re uest # <br />4 S� O5 T. <br />r:HD043-06 10/25/2021 ���.� � � Page I of 2 Well /Pump Permit <br />T <br />m <br />D <br />0 <br />0 <br />m <br />N <br />en <br />